Khoula Hospital,

Ministry of Health, Oman

MoH/DGKH/PAED/007/2014

Blood transfusion policy in NICU - Guidelines

Policy for Blood transfusion in NICU :-

Scope (Application)
This policy applies to all doctors and nursing staff working in Neonatal Intensive Care Unit
(NICU) for administration of blood and blood products. The target population is term or
preterm infants who needs blood or its components

Guideline Objective (s)

To provide clinical practice guidelines on blood and its components therapy in the neonate.

Policy
It is the policy of the Directorate General of Khoula Hospital to ensure a safe practice for the
administration of blood and its component therapy for newborn babies .

Interventions and Practices Considered

Blood or its components therapy

( 1 ) -- Whole blood :-

1.1 One unit = 450 ml donor’s blood + 63 ml anticoagulant preservative

1.2 Whole blood less than 24 hrs old is considered as fresh blood

1.3 CPDA-1 whole blood should be used in newborn

1.4 Indications :–

 Acute hypovolemia e.g. surgical blood loss,

 Massive blood transfusions

 Exchange transfusion ( plasma reduced whole blood should be used in newborns)

  ECMO

 After cardiopulmonary bypass

1.5 Dose – 10 to 15 ml / kg, Determined by clinical situation

( 2 ) -- Transfusion of RBC’S for neonates :-

2.1 Criteria for transfusion of RBC’S for neonates

 Anemia in first 24 hours ( < Hb 12 g/dl (Hct 36 %) and baby is symptomatic

 Cumulative loss of more than 10% of blood volume in 1 week in a neonate requiring
intensive care

 Hct < 30 % with an infant:

1) On < 35 % hood oxygen

2) On CPAP or mechanical ventilation with mean airway pressure < 6 cm of H2o

3) With significant apnoea or bradycardia

4) With significant tachycardia or tachypnoea

5) With low weight gain

 Hct < 35 % with an infant:

1) On > 35 % hood oxygen

2) On CPAP or mechanical ventilation with mean airway pressure ≥ 6 - 8 cm of

H2o

 Neonate with cyanotic CHD , ECMO ---- Hct less than 45%

 Acute blood loss ≥ 10% of blood vol.

 Late anemia with ≤ Hb 7 g/dl (Hct < 20 %)with low reticulocyte count and
symptomatic anemia (tachycardia, tachypnea,poor feeding, apnoea ).

2.2 Volume to be transfused 10 to 15 ml / kg to be given over 4 hrs

2.3 Furosemide 1 mg / Kg can be considered at beginning or during mid transfusion

2.4 Type of blood -- O Rh positive cross matched with baby can be given safely , Otherwise
if baby’s and mother’s blood is same , baby’s blood group can be given.
 “Once transfusion is given, it is wise to use the same group of blood for repeated
transfusions during hospital stay”.

2.5 CPDA-1 blood should be preferably used . If CPDA-1 is not available, SAGAM PRBC‘S
can be used for packed cell transfusion.

( 3 ) -- Fresh frozen plasma (FFP) :-

3.1 Indications - For treatment or prevention of clinically significant bleeding due to

deficiency of one or more coagulation factors

Such situations include –

 Isolated congenital deficiency of coagulation factor

 Severe liver disease

 DIC

 Massive large volume exchange transfusion

 HDN ( hemorrhagic disease of the newborn )

 Use of vitamin K antagonist

3.2 Dose : 10 TO 15 ML / KG to be given in 1 hour

3.3 Can be repeated at 8 to 12 hours interval if required

3.4 It increases the level of plasma coagulation factors by 20 % immediately after infusion

3.5 Administer as soon as possible after thawing

3.6 ABO compatible with recipient should be used

3.7 AB type FFP is compatible with red blood cells of all recipients

( 4 ) --- Cryoprecipitate :-

4.1 Cryoprecipitate are precipitated proteins of plasma, rich in factor VIII, Fibrinogen, von

Willebrand’s factor and coagulation factor XIII

4.2 ABO compatible with the patient should be used

4.3 Dose : 10 to 15 ml / kg

4.4 It should be given over 30 to 60 minutes

4.5 Indications :-

 von Willebrand’s disease

 Congenital deficiency of fibrinogen

 Hemophilia A ( if specific factor VIII concentrate is not available )

 Congenital deficiency of factor XIII

 Actively bleeding patient when Fibrinogen level is less than 100 mg/dL as in DIC
or massive blood replacement

( 5 ) --- Platelets :-

5.1 Thrombocytopenia is the most common haemostatic abnormality in sick newborn

infants.

5.2 The immature coagulation system in neonates contributes to an increased bleeding

risk.

5.3 Platelet transfusions are indicated for the support of selected neonates with clinically
significant quantitative or qualitative platelet disorders.

5.4 Guidelines for platelet transfusion in the neonate acknowledge the lack of evidence on
which to make recommendations and aim for a safe approach.

5.5 Experience from allo-immune thrombocytopenia indicates that in a well term neonate,
the risk of significant haemorrhage as a result of thrombocytopenia is unlikely at counts
above 30 x 109/L, however for preterm infants, despite the lack of evidence, a higher

threshold of 50 x 109/L is recommended.

5.6 Early thrombocytopenia has a consistent pattern with nadir around day 4 and

recovery of platelets number by day 7 to 10 of life.

5.7 Indications :-

 Absolute thrombocytopenia without bleeding. since spontaneous bleeding can

occur with a platelet count less than 30,000/µ L , transfusion is recommended

 Absolute thrombocytopenia with bleeding ( platelets count < 50,000/µ L )

 Platelet count < 50,000 /µ L in neonates with sepsis, DIC , NEC

 Thrombocytopenia ( < 50,000/ µ L ) secondary to massive transfusion,

  Platelet counts should be more than 50,000 /µ L in surgical procedure’s like
lumbar puncture, liver biopsy.

 For bone marrow biopsy low platelet’s is not a contraindication, only adequate
pressure is required

 For ECMO , major organ bleeding ,major neurosurgical intervention,

cardiopulmonary bypass < 100 / µ L

5.8 Amount of transfusion - 15 to 20 ml / kg

5.9 Transfusion on higher side is preferable so as to raise the platelet count sufficiently
and to avoid repeated platelet transfusions.

5.10 One unit / 10 kg body weight raises platelets by 30,000 / micro L

5.11 Rate of transfusion:- Transfuse as soon as possible and should be completed in about
20 minutes.

5.12 After one hour of platelet transfusion, platelet count can evaluate its survival in
circulation.

5.13 Avoid incompatible plasma.

5.14 Transfusing platelets from group O donors to group A, B or AB recipients may result

in haemolysis (from anti-A and anti-B in group O plasma).

5.15 Also, the International Forum on transfusion of apheresis platelets and ABO blood
groups, concludes that the transfusion of group O platelets to non-O recipients should
be avoided.

5.16 Children and infants are more at risk than adults due to their small blood volume.

5.17 Platelet product group

Patient’s First choice Second choice Third choice

ABO group

O O - -

A A B O

B B A O

AB AB B or A O

5.18 -- Contraindications
  Thrombotic thrombocytopenic purpura

 Hemolytic uremic syndrome

 Heparin induced thrombocytopenia

 Idiopathic thrombocytopenic purpura, unless bleeding is life threatening

Hazards/Complications to be watched for :-

 Transfusion-related circulatory overload (TACO)

 Febrile non-haemolytic transfusion reactions (FNHTR)

 Severe allergic reactions (anaphylactoid reactions or anaphylaxis)

 Minor allergic reactions (urticaria)

 Transfusion associated infections ( HIV ,Hepatitis(B , C),syphilis

 Post-transfusion purpura (PTP)

 Febrile non-haemolytic transfusion reactions (FNHTR)

 Complications of massive transfusion

Hypothermia, Dilutional coagulopathy, Hypocalcaemia,

Hypomagnesaemia, citrate toxicity, Lactic acidosis,

Hyperkalaemia, Air embolism

 Transfusion-related Acute Lung Injury (TRALI) &

 (TA-GVHD) Transfusion-associated graft versus host disease

How to prevent complication of blood transfusions :-

 Immunosensitization can be avoided by use of leucocyte depletion filter

 CMV risk can be reduced by use of CMV negative blood or use of leucocyte depletion
filter

 Graft versus host disease can be prevented by use of leucocyte depletion filter or by
irradiation ( 2500 rads )
  Use of multiple pediatric transfer packs allows Infant to receive multiple transfusions
in times of need from the same bag ( donor )

Responsibilities
1. Director of Paediatrics shall:
a. Ensure that all doctors and nursing staff are aware of this policy
b. Ensure that this guideline is updated as per guideline of Khoula hospital
2. Nursing In-charge of Neonatal intensive care unit shall:
a. Ensure that all nursing staff working in neonatal intensive care unit are aware of
this guideline & emphasize the importance of following it
3. Paediatrician shall:
a. Identify the babies who need blood products
b. Explain to parents about need of the blood products
c. Administer blood products according to this policy
d. If any complications occurs, discontinue transfusion immediately, to be notified
to blood bank immediately.

4. The nursing staff shall:

a. Adhere to this guideline
b. Continue to monitor baby closely and report any complications to paediatrician
immediately.
c. If any complications occurs, discontinue transfusion immediately , to be notified
to blood bank immediately.
References :-
th
1. Blood component therapy Anesthesia Tutorial : 11 June 2012; Royal Devon and
Exeter Hospital, UK, 2012

2. Australian and New Zealand Society of Blood Transfusion Ltd Royal College of
Nursing Australia ; 2nd Edition, December, 2011

3. American college of pathologists and American association of Blood Bank Technical

Manual , September , 2010

4. Blood and blood component therapy in neonates; AIIMS- NICU protocols, 2008

5. Evidence-Based Platelet Transfusion Guidelines; American society of Hematology

Education Programme Book, 2007

6. Transfusion of Blood Components to Infants under Four Months: Irish Medical

Journal Supplement; June 2007, Volume 100, Number 6

7. Neonatal transfusion practice; Arch Dis Child Fetal Neonatal Ed 2004;89:F101-F107

8. Blood Transfusion ; The Royal Children’s Hospital Melbourne 2002; 42: 1398 - 1413